How to make a terrible, horrible, no good, very bad bill even worse

It’s BACK—the terrible, horrible, no good, very bad bill to repeal and replace the Affordable Care Act (ACA).  Last month, I blogged about how the bill, called the American Health Care Act, was the worst legislation for health care of any that I have seen in 38 years of advocacy for doctors and patients.  While it was good that this bill was pulled by House Speaker Paul Ryan on March 24 due to a lack of support among Republican lawmakers, he may bring it back for a vote as early as this Friday, April 28. Only, this time, believe it or not, with changes designed to win support from hard-right conservatives that make the original bill even worse for patients.  I guess we will have to call this version the even more terrible, horrible, no good, very bad, bill for patient care. 

On Tuesday, ACP was able to confirm that the House GOP leadership and Trump administration were close to reaching a deal with 20 or so of the most conservative lawmakers, the self-described “Freedom Caucus.” Unfortunately, as explained in a detailed letter that we sent to all members of Congress later that day, the proposed “compromise”  would gut existing law protections for people with preexisting medical conditions and requirements that insurers cover essential benefits by allowing states to opt-out of such requirements.  And today, we joined in a coalition letter with 5 other physician membership organizations, collectively representing over 560,000 physician and medical student members, expressing our combined opposition to the “compromise” bill. 

Let me be clear why the compromise makes a terrible bill even worse:

It would allow states to obtain “waivers” to opt-out of the ACA’s prohibition on insurers charging more to people with preexisting conditions.  That’s right, the “compromise” would return us to the pre-ACA days when states often allowed insurers to charge whatever they wanted to people with conditions like asthma, diabetes or dozens of other conditions that were considered to be “declinable” by insurers.  As ACP explained in its letter to Congress, “Before the ACA, insurance plans sold in the individual insurance market in all but five states typically maintained lists of so-called "declinable" medical conditions—including asthma, diabetes, arthritis, obesity, stroke, or pregnancy, or having been diagnosed with cancer in the past 10 years. Even if a revised bill would not explicitly repeal the current law’s guaranteed-issue requirement—which requires insurers to offer coverage to persons with pre-existing conditions like these—guaranteed issue without community rating allows insurers to charge as much as they believe a patient’s treatment will cost. The result would be that many patients with pre-existing conditions would be offered coverage that costs them thousands of dollars more for the care that they need, and in the case of patients with expensive conditions like cancer, even hundreds of thousands more.”

The bill does say that states would have to set up or participate in high risk pools for people with preexisting conditions in order to be approved for a waiver.  But we know from experience that underfunded high-risk pools, which were common before the ACA, typically had very high premiums and deductibles, long wait lists, and limited benefits, making the coverage unaffordable for those who need it most. And the amended AHCA does not provide anywhere near the amount of money that could make high risk pools viable, and does not set any standards or funding levels that states must meet to ensure that coverage under the pools are affordable and benefits are adequate.

It would allow states to obtain “waivers” to opt-out of the ACA’s requirement that all insurers cover 10 categories of essential medical care services.   We know from the pre-ACA days what this could mean for patients: in many states, insurers will once again be allowed to decline coverage of needed benefits like physician and hospital visits, maternity care and contraception, mental health and substance use disorder treatments, preventive services, and prescription drugs. “Prior to passage of the ACA, 62% of individual market enrollees did not have coverage of maternity services, 34% did not have substance-use disorder services, 18% did not have mental-health services and 9% did not have coverage for prescription drugs,” ACP wrote to Congress.  “A recent independent analysis found that the AHCA’s repeal of current law required benefits would result in patients on average paying $1,952 more for cancer drugs; $1,807 for drugs for heart disease; $1,127 for drugs to treat lung diseases; $1,607 for drugs to treat mental illnesses; $4,940 for inpatient admission for mental health; $4,555 for inpatient admission for substance use treatment; and $8,501 for maternity care. Such increased costs would make it practically impossible for many patients to avail themselves of the care they need. The result will be delays in getting treatment until their illnesses present at a more advanced, less treatable, and more expensive stage, or not keeping up with life-saving medications prescribed by their physicians.”

And repeal of the essential benefit requirements would mean that insurers would no longer be required to cover substance use disorder treatments.  “Allowing states to eliminate the [Essential Health Benefits] will threaten our nation’s fight against the opioid epidemic,” ACP told Congress. “A study concluded that with repeal of the ACA, ‘approximately 1,253,000 people with serious mental disorders and about 2.8 million Americans with a substance use disorder, of whom about 222,000 have an opioid disorder, would lose some or all of their insurance coverage.’”

And the “compromise” would even gut the ACA’s ban on insurers imposing annual or lifetime limits on coverage, because under current law insurers are only banned from imposing dollar limits on services that are included in the mandatory essential health benefits package.   If a state, for example, decided that chemotherapy was no longer an essential benefit in your state, there would be nothing stopping insurers from putting a $100,000 lifetime dollar limit (if even that much) on coverage for your cancer treatment.  After that, sorry, you’d be on your own, forcing choices like lose your house, or lose your health care, you decide. 

The bill’s gutting of prohibition on annual and lifetime coverage limits would affect not only people who get coverage  through health plans sold through the ACA’s marketplaces, but also the vast majority of people who get coverage from their employer, as analyst Tim Jost explains today in a Health Affairs blog.  “Since the ACA’s prohibitions of lifetime and annual limits and cap on out-of-pocket expenditures also only apply to essential health benefits, states granted a waiver would be able to define these protections as well. The changes to the lifetime and annual limits and to the out-of-pocket caps could potentially apply as well to large group and self-insured employer plans.” Jost also observes that although the amendment says that “’nothing in this Act shall be construed as permitting insurers to limit access to health coverage for individuals with preexisting conditions,” but that is precisely what health status underwriting [which could return in states that obtain waivers] does. Health status underwriting could effectively make coverage completely unaffordable to people with preexisting conditions.”  

And remember, even before the proposed compromise made the AHCA even worse, the original bill was unacceptable because it cut, capped, and block granted Medicaid, ended funding for Medicaid expansion, and replaced the ACA’s income-based premium and cost-sharing subsidies with regressive age-based ones that would make premiums and deductibles unaffordable for older and sicker patients, resulting in 24 million more uninsured persons, according to the Congressional Budget Office.

So if politicians tell you that people with preexisting conditions are protected by the amended AHCA, don’t believe them.  They are either lying, or more charitably, don’t understand what is being proposed.  And if they say premiums will be lower, keep in mind that while this might be true for some young and healthy people, it would be at the expense of making health care unaffordable for older and sicker patients.

Yet Speaker Ryan is counting votes right now in the hope of bringing the bill to a vote by Friday so it can be passed by the House of Representatives during President Trump’s first 100 days.

Don’t let Speaker Ryan and President Trump bring their even more terrible, horrible, no good, very bad bill back from the dead.  Call your member of Congress today, especially if he or she is a moderate Republican or one in a competitive district, at 202-224-3121 and help us put a nail in the AHCA’s coffin.  (And even if you have called before, they need to hear from you again).  Don't put this off, tomorrow could be too late.  Patients are depending on you.

Today’s question: did you make your call to Congress to urge them to vote no on the even more terrible, horrible, no good, very bad AHCA!